Malariatapuksia Goalla 2006joulu-2007tammi

malariamalarone kirjoitti:

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Surveillance Report volume 12
issue 1
date 11 January 2007



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Recent cases of falciparum malaria imported to Europe from Goa, India, December 2006-January 2007
Outbreak of legionnaires’ disease among tourists staying at a hotel in Phuket, Thailand
First isolation of Clostridium difficile 027 in Japan
A comparison of public domain software for outbreak investigations: Epi Info and EpiData
The BURDEN project - Assessing the burden of resistance and disease in Europe

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Recent cases of falciparum malaria imported to Europe from Goa, India, December 2006-January 2007

T Jelinek1 ([email protected]), R Behrens2, Z Bisoffi3, A Bjorkmann4, J Gascon5, U Hellgren6, E Petersen7, T Zoller8 on behalf of TropNetEurop, the European Network on Imported Infectious Disease Surveillance R H Andersen9, Anders Blaxhult10,

1 Berlin Center for Travel & Tropical Medicine, Berlin, Germany
2 Hospital for Tropical Diseases, London, UK
3 Centro per le Malattie Tropicali, Ospedale S. Cuore, Negrar (Verona), Italy
4 Karolinska Hosiptal, Department of Medicine, Unit of Infectious Diseases, Stockholm
5 Sección de Medicina Tropical, Hospital Clinic, Barcelona, Spain
6 Department of Infectious Diseases, Karolinska University Hospital Huddinge, Stockholm
7 Department of Infectious Diseases, Aarhus University Hospital, Skejby, Aarhus, Denmark
8 Medizinische Klinik mit Schwerpunkt Infektiologie, Charite/Campus Virchow-Klinikum, Berlin, Germany
9 Statens Serum Institut, Copenhagen, Denmark
10 Swedish Institute for Infectious Disease Control, Stockholm, Sweden

An increase in numbers of malaria cases has recently been reported in travellers returning from India, in particular from the state of Goa, on the west coast. These cases have been reported to the European Network on Imported Infectious Disease Surveillance (TropNetEurop, http://www.tropnet.net). In the past two years, there have been no reports of malaria in European travellers to Goa. However, since late November 2006, the malaria surveillance map of the network has shownan unusually intensive signal from India [1], indicating an increase in the number of malaria reports from that region, including Goa.
By 10 January, eight patients had been reported: two in Germany, four in Denmark, and two in Sweden. With the exception of two Danish cases, all patients travelled independently of one another. The two German patients, one of the Swedish patients and one of the Danish patients stayed in Goa for 2-3 weeks and had not visited other regions within India.
Germany cases 1 and 2
The two German patients developed severe malaria and were treated in an intensive care unit with artesunate/doxycycline. Both travellers (a woman in her 50s and a man in his 40s), travelling independently, spent 14 days at two popular coastal resorts in Goa. Neither took any malaria chemoprophylaxis. One traveller developed a hyperparasitaemia of 25%, both had signs of cerebral malaria and acute renal failure. They were admitted to the hospital on December 10 and 11 respectively, and made a full recovery.

Sweden case 1
A Swede in his 40s travelled to Goa for two and a half weeks in November-December 2006. He visited a beach in northern Goa and stayed in a beach hotel. He slept under a mosquito net but without air conditioning. He did not take any malaria chemoprophylaxis, in accordance with the Swedish recommendations for travellers to that area [2]. Five days after his return to Sweden, he developed a sudden fever, was diagnosed with a probable pneumonia and treated with amoxicillin/clavulanic acid for three days. With no improvement in his condition he was admitted to hospital seven days later, where a diagnosis of Plasmodium falciparum monoinfection with 0.4% parasitaemia was made. This diagnosis was delayed because travel history had not been obtained earlier. The patient was treated with mefloquine and made an uneventful recovery.

Sweden case 2
A Swede in her 50s visited Goa for a two week holiday in November-December 2006, and did not take any malaria chemoprophylaxis. Staying in a coastal area in Goa, she travelled for three days to an area 300 km inland. She developed symptoms the day before her return to Sweden. On her return she visited her general practitioner twice, and a diagnosis of bronchitis was made and treatment with amoxicillin/clavulanic acid started. The patient was admitted to hospital with a fever of 40° C, hypotensive thrombocytopenia and hyponatraemia, diagnosis with P. falciparum malaria and a 1.5% parasitaemia, 16 days after her return. Malaria treatment was initiated with quinine and proguanil/atovaquone. Her condition gradually improved and she was discharged from hospital a week later.

Denmark case 1
A Dane in his 60s visited Goa for a two week holiday in December 2006. He stayed in Goa but visited a waterfall in an area east of Goa. His hotel accommodation in Goa had no air conditioning and no mosquito net. In accordance with the Danish travel recommendations at the time [3] he did not take any malaria chemoprophylaxis. He developed symptoms of fever and headache nine days after his return to Denmark, and was admitted to a local hospital three days later. Two days later, he was diagnosed with P. falciparum malaria, 0.3 % parasitaemia, and transferred to an infectious disease ward. On admission he had eye muscle paresis but with a normal cerebral magnetic resonance imaging scan, and thrombocytopenia. Because of these complications, he was started on intravenous quinine followed by mefloquine, and made an uneventful recovery.

Denmark case 2
A Dane in his 20s travelled to Goa for a two week holiday in November 2006, and stayed in a tourist hotel. He did not take any chemoprophylaxis. His symptoms developed in early December, one week after his return to Denmark, and he was admitted to hospital three days later with a low grade fever. Microscopy revealed a parasitaemia of 1%. He was treated with mefloquine with rapid clinical response and cleared his parasitaemia uneventfully.

Denmark cases 3 and 4
Two men in their 20s travelled together to India for three weeks from mid October to the beginning of November 2006. They visited Punjab, Goa, Delhi and Mumbai. Both took chloroquine tablets only. The Danish Statens Serum Institut considers chloroquine-only prophylaxis to be insufficient for malarious areas in India and recommends taking both chloroquine and proguanil [3]. Both men developed fever, headache and gastrointestinal symptoms on the last day of their holiday. One of the patients was diagnosed that day with P. falciparum malaria by microscopy and was successfully treated with proguanil/atovaquone (four tablets per day for three days). The diagnosis was confirmed by Binax NOW antigen test. The second patient initially tested negative by microscopy for malaria on three consecutive days while still taking chloroquine, but his blood tested positive on six weeks after onset of symptoms, and he was successfully treated with proguanil/atovaquone.

Comment from TropNetEurop
Goa, a popular winter resort for European tourists who visit beach hotels and resorts along the coast, has previously been considered to be very low-risk for malaria infection for travellers. It appears that this cluster of cases of imported falciparum malaria, acquired in the area to the north of Panaji, the capital of Goa, has coincided with a period of intense rainfall (50% above average) in the Goan and Konokan region since October 2006 [4]. This may be the cause of increased vector breeding and transmission during the current rainy season.

The risk of infection will presumably decline with the coming dry season. Currently, however, there may be increased risk of malaria transmission and therefore all travellers who intend to visit this region of India are advised to use mosquito bite avoidance measures. Visitors may consider using WHO type IV prevention [5], which is mosquito bite prevention plus chemoprophylaxis with atovaquone/proguanil, doxycycline, or mefloquine, or they may consider travelling with emergency standby treatment. Anyone who becomes unwell while on holiday or shortly after their return should seek medical attention promptly. Falciparum malaria can be a life-threatening illness. The diagnosis can only be made if a careful travel history is taken, and testing done early, even for regions where malaria is not normally recognised. The risk in Goa will be monitored and we expect transmission to cease as the rainy season ends in early 2007.

Changes made in recommendations for travellers in some EU member states
In December 2006, Denmark’s Statens Serum Institut changed its malaria advice until further notice, as a precautionary measure. Until there is information on possible chloroquine resistance, the new recommendation for Danish travellers to Goa is type IV chemoprophylaxis, as described above [3]. Previously no chemoprophylaxis was advised.

In Sweden, no changes in the general recommendations for travellers have been made [2] but the Swedish Institute for Infectious Disease Control has informed about the Goa cases on their home page and sent a letter to all departments of Infectious Diseases and Infectious Disease Control. In this letter it is stated that: "Until we know more about the present malaria situation, malaria prophylaxis can be considered for travellers visiting Goa. The drugs that might be used are Malarone, Lariam (mefloquine) or doxycycline". In addition, there have been several news spots on this topic on the national television.

No changes in the general recommendations for travellers have been made in Germany.

In addition, the recent cluster of malaria cases imported from Goa has also prompted the Advisory Committee for Malaria Prevention in United Kingdom Travellers (ACMP) to issue temporary change to its recommendations. The ACMP advises that travel advisors should highlight the risk of malaria, instruct on the use of mosquito bite avoidance measures [6], and recommend malaria chemoprophylaxis to those travellers who will be visiting Goa, particularly areas north of Panaji, and who will be remote from medical care. This advice remains in effect until further notice as the situation is clarified. The recommended chemoprophylaxis is chloroquine plus proguanil. Alternatives are mefloquine, atovaquone plus proguanil, or doxycycline.

Acknowledgements:
Thomas Zoller Charite hospital, Berlin, Germany; Johan Iversen, Department of Infectious Diseases, Hvidovre Hospital, Denmark; Toke Barfod, Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark;


References:
TropNetEurop Friends & Observers Sentinel Surveillance Report: November 2006. Map on p. 3. http://www.tropnet.net/reports_friends/pdf_reports_friends/nov06_dengue2006_friends.pdf
Rekommendationer för malariaprofylax. 2006. (in Swedish) http://www.smittskyddsinstitutet.se/upload/Publikationer/Malariaprofylax-2006.pdf
Ændrede anbefalinger for malariaprofylakse for rejsende til Goa i Indien. 22 december 2006. (in Danish only). http://www.ssi.dk/sw174.asp?PAGE=2&ArtNo=3478761
Rainfall maps, India Meteorological Department. http://www.imd.ernet.in/section/hydro/dynamic/seasonal-rainfall.htm
Country list; Vaccination requirements and malaria situation. In: International travel and health publication. Geneva: World Health Organization; 2005. http://whqlibdoc.who.int/publications/2005/9241580364_country_list.pdf
The National Travel Health Network and Centre (NaTHNaC). Insect bite avoidance. London: NaTHNaC, 2006. http://www.nathnac.org/pro/factsheets/iba.htm
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Outbreak of legionnaires’ disease among tourists staying at a hotel in Phuket, Thailand

Lara Payne1 ([email protected], Yvonne Andersson1, Luise Ledet Muller1, Hans Blystad2, Tran Minh Nhu Nguyen3, Petri Ruutu3, Carol Joseph4, Katherine Ricketts4

1Smittskyddinstitutet, Solna, Sweden
2Folkehelseinstituttet, Oslo, Sweden
3 Kansanterveyslaitos, Helsinki, Finland
4 EWGLINET, Centre for Infections, Health Protection Agency, London, United Kingdom

Four cases of legionnaires’ disease have recently been reported in one Norwegian, one Finn and two people from Sweden. These patients were all among guests staying at a hotel in Patong Beach, Phuket, Thailand since 20 November 2006. The patients became ill between 6-9 December and on 26 December 2006. Three cases are in men (aged 24 – 66) and one is in a woman (aged 51). None of the cases has been fatal.
The responsible national institutes have informed tour operators with whom patients travelled about the suspected link to the hotel. Some tour operators have stopped using the hotel for their guests temporarily, and all tour operators in Norway, Finland and Sweden who used the hotel are informing all guests who stayed at the hotel since 20 November 2006 by e-mail or post.

Reporting of the individual cases to the European Working Group for Legionella Infections (EWGLI) resulted in a cluster alert being issued on the 3 January 2006 within the EWGLI network, and to the International Federation of Tour Operators, World Health Organization and European Centre for Disease Control (ECDC). Following confirmation of the fourth case from Norway, an alert was issued to the Early Warning and Response System on the 9 January 2007.

The WHO and ECDC are co-ordinating follow-up of recent visitors to the hotel who may not have been contacted through tour operators. Information about the cluster and advice to returning travellers has been issued on the following national institute websites (National Public Health Institute Finland: http://www.ktl.fi, Norwegian Institute for Public Health: http://www.fhi.no, Swedish Institute for Infectious Disease Control: http://www.smittskyddsinstitutet.se).

Legionnaires’ disease (or legionellosis) is a bacterial infection which presents as an atypical form of pneumonia, treatable with antibiotics. Person to person transmission of the infection has never been demonstrated. Incubation time is normally 2-10 days. Symptoms include fever, chills, headache and muscle pain followed by a dry cough and breathing difficulties associated with the pneumonia.


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First isolation of Clostridium difficile 027 in Japan

H Kato1 ([email protected]), Y Ito2, RJ van den Berg3, EJ Kuijper3, Y Arakawa1

1Department of Bacterial Pathogenesis and Infection Control, National Institute of Infectious Diseases, Tokyo, Japan
2Department of Internal Medicine, Gifu Red Cross Hospital, Gifu, Japan,
3National Reference Laboratory for Clostridium difficile, Department of Medical Microbiology, Leiden University Medical Center and RIVM, Bilthoven, Leiden, The Netherlands


We report the first isolation of a variant strain of Clostridium difficile from a patient with pseudomembranous colitis in Japan. The strain was chararacterised as North American pulsed field gel electrophoresis type 1 (NAP1), PCR ribotype 027, toxinotype III. This strain has been reported previously as the cause of outbreaks in Canada, United States, the Netherlands, the United Kingdom (UK), France, and Belgium. [1,2,3,4,5,6].

Case report
A 30 year old Japanese woman with no history of previous hospital admission was admitted to a hospital for ulcerative colitis in mid-March 2005. She had received medical treatment for ulcerative colitis as an outpatient since 2004. She had not been abroad just before this admission. On admission, treatment with antibiotics (levofloxacin and cefozopran hydrochloride) was started, and, one month after admission, endoscopy detected rectal pseudomembranes. The intestinal symptoms (mucus in stool) were mild and, after she started treatment with vancomycin, these symptoms resolved in a few days. The patient developed a relapse of diarrhoea on 10 May 2005, and a colonoscopy showed pseudomembranes along the entire region of her colon. Metronidazole therapy was started, but the symptoms were still present after six days, and a further colonoscopy revealed no improvement. Therapy was switched to vancomycin, and the diarrhoea resolved in five days.

Bacterial identification
Stool culture of specimens taken during both episodes yielded C. difficile. The stool specimen at the relapse was available for toxin detection, and was positive for toxin A and toxin B by enzyme immuno-assay and cell culture assay. The two isolates were toxin A-positive, toxin B-positive and positive for the binary toxin gene by PCR. Analysis by PCR ribotyping and slpA sequence typing was performed on the two isolates, and both were identified as the same type of a strain characterised as C. difficile 027 [2]. These typing results were confirmed by multi-locus variable number tandem repeats analysis (MLVA). Sequence analysis of tcdC in these isolates showed a single-base pair deletion at position 117 as well as a well-documented 18-bp deletion, which were identical to the sequence results in that of the reference strain of C. difficile 027. When examined by E-test, both of isolates were sensitive to gatifloxacin (MIC=0.5), moxifloxacin (MIC=0.5), clindamycin (MIC=1.0) and metronidazole (MIC=0.25). More than 150 C. difficile isolates collected between 2003 and 2006 at five medical facilities, including the hospital where the patient was admitted were examined, and none of those isolates was typed as 027.

Discussion
This is the first report of the 027 strain of C. difficile in Japan. The infection was most likely hospital acquired. As far as investigated to date, C. difficile outbreaks in multiple hospitals in Japan have been associated with a different strain: PCR ribotype smz , and outbreaks caused by the 027 strain have not been found in Japan. It is unknown whether the 027 strain was present in Japan previously or whether it has come from other countries recently. In contrast to 027 strains circulating in North America and Europe, the Japanese isolate was susceptible to the newer fluoroquinolones, as has been reported in the 027 isolates obtained before 2001 in North America [2].

Acknowledgement
We thank G E Killgore of the Centers for Disease Control and Prevention, United States for providing the reference strain of C. difficile 027.

References:
MacCannell DR, Louie TJ, Gregson DB, Laverdiere M, Labbe AC, Laing F, et al. Molecular analysis of Clostridium difficile PCR ribotype 027 isolates from Eastern and Western Canada. J Clin Microbiol 2006; 44(6):2147-2152.
McDonald LC, Killgore GE, Thompson A, Owens RC, Jr., Kazakova SV, Sambol SP, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005; 8; 353(23):2433-2441.
Kuijper EJ, van den Berg RJ, Debast S, Visser CE, Veenendaal D, Troelstra A, et al. Clostridium difficile ribotype 027, toxinotype III, the Netherlands. Emerg Infect Dis 2006; 12 (5):827-830
Smith, A. Outbreak of Clostridium difficile infection in an English hospital linked to hypertoxin-producing strains in Canada and the US. Euro Surveill 2005; 10(6):E050630.2 http://www.eurosurveillance.org/ew/2005/050630.asp#2
Coignard B, Barbut F, Blanckaert K, Thiolet JM, Poujol I, Carbonne A, et al. Emergence of Clostridium difficile toxinotype III, PCR-ribotype 027-associated disease, France, 2006; Euro Surveill 2006; 11(9):E060914.1 http://www.eurosurveillance.org/ew/2006/060914.asp#1
Delmée M, Ramboer I, Van Broeck J, Suetens C. Epidemiology of Clostridium difficile toxinotype III, PCR-ribotype 027 associated disease in Belgium, 2006. Euro Surveill 2006; 11(9):E060914.2; http://www.eurosurveillance.org/ew/2006/060914.asp#2
Indra A, Huhulescu S, Hasenberger P, Schmid D, Alfery C, Würzner R. et al. First isolation of Clostridium difficile PCR ribotype 027 in Austria. Euro Surveill 2006; 11(9): E060914.3; http://www.eurosurveillance.org/ew/2006/060914.asp#3
Kato, H, Yokoyama T, Arakawa Y. Typing by sequencing the slpA gene of Clostridium difficile strains causing multiple outbreaks in Japan. J Med Microbiol 2005; 54(2):167-171.
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A comparison of public domain software for outbreak investigations: Epi Info and EpiData

G Kafatos ([email protected]), NQ Verlander, D Gelb, E Arnold, A Charlett

Statistics, Modelling and Bioinformatics Department, Health Protection Agency Centre for Infections, London, UK

Since the early 1980s, there has been an increase in the number of outbreaks investigated using analytical epidemiology since it became widely accepted that microbiological investigation alone is often insufficient [1, 2, 3]. This increase has also been encouraged by a growing availability of statistical tools within public health and the establishment of international and national training programmes and courses (such as the European Programme for Intervention Epidemiology Training). In 1985, a team at the Centers for Disease Control and Prevention (CDC) in the United States created a suite of public domain computer programs called Epi Info (http://www.cdc.gov/epiinfo/), which were designed to support field epidemiological investigations of outbreaks.
We compare the two most recent versions of Epi Info, and EpiData, a public domain software based on Epi Info 6.04d.

Epi Info 6.04d
Since the release of its first version written for the DOS-environment in 1986, Epi Info quickly became very popular amongst epidemiologists and other public health professionals. Its popularity is demonstrated by the fact that the program is available in 16 different languages. In 2001, the CDC released the final version of Epi Info DOS (Epi Info 6.04d).

Epi Info DOS consists of a suite of programs, which provide all that is necessary to support an outbreak investigation. It is a flexible, versatile tool that permits the construction of a data entry system and an underlying database with great speed, which is something greatly appreciated under the time pressures of an on-going outbreak investigation.
In addition, Epi Info DOS contains an analysis module for elementary statistical analysis that is very useful for outbreak investigations where the outcome is often binary (case/control, ill/not ill). The ‘tables’ command provides all the necessary measures of the strength of association, such as odds ratios (OR) and risk ratios (RR), their confidence intervals, and hypothesis tests. It also allows stratified analysis to remove the effects of up to three confounding factors. The ‘csample’ module enables cluster analysis and stratified designed surveys. Epi Info DOS was complemented by a CDC public domain mapping software (Epi Map, CDC), allowing area maps to be produced directly from Epi Info files.

Epi Info for Windows 3.3.2
Despite the unprecedented success of Epi Info DOS, by the late 1990s, the widespread uptake of the Microsoft Windows operating system for personal computers meant that a Windows version was needed. Epi Info 2000 (Epi Info 3) for Windows was released in 2000. However, there are substantial differences compared with Epi Info DOS.

The analysis capability of Epi Info DOS was carried forward to Epi Info 3 while adding the ability to estimate proportional hazards models and integrating logistic regression and mapping facilities into the package. The software uses components from commercial software, which enhances its compatibility with ‘industry standards’ such as Microsoft Office Access 2003. However, this is also the main disadvantage, since it has resulted in the loss of some functions (such as copying and pasting of fields in questionnaire creation and of check commands between different fields) reducing the speed of usage, a key requisite for outbreak investigations. Moreover, because the principle of simplicity and easy use which underpinned the creation of Epi Info DOS was not carried forward to Epi Info 3, those who have worked with Epi Info DOS will need training to become proficient users of Epi Info 3.

EpiData 3.1 (120306)
EpiData was initially released in 2000 by a non-profit organisation in Denmark (EpiData Association, http://www.epidata.dk/). The current version 3.1 became available in 2006. This software was developed specifically to translate Epi Info DOS into Windows software by using the Epi Info DOS file structures and command language wherever possible.

Certain restrictions in file size were removed but those dependent upon file structures remain. Construction of a data entry system using EpiData is very simple, especially if the original questionnaire has been constructed in a Windows-based word processing software where it can be either opened as a text file or copied directly into EpiData.

For validating double-entered data (a common practice to ensure high quality data) the ‘Validate Duplicate Files’ option in EpiData has built on the dual entry validation capability within Epi Info DOS. Two additional options to either ‘Ignore text fields’ or ‘Ignore letter-case in text fields’ resolve the problems that occur when comparing text fields (i.e. two identical text fields are considered different by the software if one is written in capital and the other in lower-case letters).

EpiData Analysis (v1.1 Build 68)
When EpiData was originally released, one major disadvantage was its lack of analytical statistical tools. This was addressed with the introduction of EpiData Analysis in 2005. This provides the statistical methods available within the analysis module of Epi Info DOS, but has greatly improved data manipulation facilities.

A wide range of statistical tools exists within Epi Data Analysis, including analysis of variance, which provides a t-test for independent groups, chi-square and Fisher’s exact tests of association, nonparametric tests of difference in location between two groups, and estimates of measures of association with confidence intervals. The graphical capability in EpiData Analysis is much better than Epi Info DOS, with more options and flexibility. While the graphs are acceptable for descriptive purposes, there will probably always be limitations in producing publication quality graphs. A new capability within EpiData Analysis is the ability to produce statistical process control (SPC) charts for performance monitoring applicable for surveillance data.

Discussion
Two public domain software packages have been developed based on the classic DOS version of Epi Info. There does seem to be a divergence in the development of EpiData (Entry and Analysis) and Epi Info 3, which is surprising given their common ancestor, Epi Info DOS. While EpiData has aimed to keep the functionality and interface of Epi Info DOS available, Epi Info 3 appears to be developing into a more general software to support epidemiologists rather than keeping with the original concept of an efficient and relatively simple software for outbreak investigation.

It is difficult to decide which of the two development directions will best meet the needs of epidemiologists over the next twenty years. It is possible that there is a place for both. The DOS version of Epi Info was extremely well-structured and efficient and, as EpiData has remained faithful to this concept, this could be seen as its natural successor. With the requirement for more sophisticated analytical methods to overcome issues such as confounding, it may be that Epi Info 3 will be better placed. However, it is now moving into a very competitive arena where commercial software has predominated. The authors would recommend EpiData 3.1 and EpiData Analysis v1.1 software packages for those involved in the investigation of infectious disease outbreaks for their speed and simplicity of use in a Windows environment.

Reviewed software:
Epi Info, version 6.04d for DOS and version 3.3.2 for Windows
Centers for Disease Control and Prevention (CDC), Atlanta, Georgia 30333
Can be downloaded from www.cdc.gov/epiinfo/Epi6/ei6.htm (DOS) and www.cdc.gov/epiinfo/ (Windows)

EpiData Entry, version 3.1 (120306) and EpiData Analysis, version 1.1 Build 68
The EpiData Association, att. Jens Lauritsen, Enghavevej 34, DK5230 Odense M, Denmark
Can be downloaded from www.epidata.dk/download.php


References:
Fonseca MGP & Armenian HK (1991) Use of the Case-Control Method in Outbreak Investigations. American Journal of Epidemiology 133: 748-752
O'Brien SJ, Elson R, Gillespie IA, Adak GK, & Cowden JM (2002). Surveillance of foodborne outbreaks of infectious intestinal disease in England and Wales 1992-1999: contributing to evidence-based food policy? Public Health 116: 75-80
Palmer SR (1989) Epidemiology in search of infectious diseases: methods in outbreak investigation. Journal of Epidemiology and Community Health 43: 311-314
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The BURDEN project - Assessing the burden of resistance and disease in Europe

U Frank1 ([email protected]), on behalf of the BURDEN Study Group

1Institut f. Umweltmedizin und Krankenhaushygiene der Universitätsklinik Freiburg, Germany

The emergence and spread of antimicrobial resistance has become a major public health threat in Europe. The number of infections caused by resistant pathogens continues to increase in the European Union (EU) and worldwide [1,2]. Treating illness, which includes infectious disease, already places a resource burden on society. Infectious disease caused by pathogens which have developed antimicrobial resistance increases societal costs further, because these infections usually require prolonged and more expensive medical treatment than infections caused by non-resistant pathogens, patients are off work for longer, and there are more costs due to increased morbidity and mortality. The emergence of resistant pathogens is likely to lead to already scarce healthcare resources being diverted to infection control efforts. The long-term implications include loss of confidence in the medical profession and public healthcare delivery system provided or regulated by governments. Therefore, it is extremely important to give realistic estimates of the burden of disease and the costs caused by antimicrobial resistant pathogens in member states and accession countries of the EU.
There are already several important national surveillance systems and EU projects looking at antimicrobial resistance, including as EARSS (European Antimicrobial Resistance Surveillance System, http://www.rivm.nl/earss), HELICS (Hospital in Europe Link for Infection Control through Surveillance, http://helics.univ-lyon1.fr/helicshome.htm), IPSE (Improving Patient Safety in Europe, http://helics.univ-lyon1.fr) and ESAC (European Surveillance of Antimicrobial Consumption, http://www.esac.ua.ac.be). Since 1998, EARSS has been generating valid and comparable data on antimicrobial resistance, with clinical and epidemiological relevance for 31 countries. These data illustrate the magnitude of the problem throughout the European region. Since 2001, ESAC has collected information on the use of antimicrobial drugs in Europe, providing an insight into one of the major driving forces of antimicrobial resistance in European countries. Because of the wide variety of health systems across the continent, it is difficult to compare individual studies carried out in different countries to analyse to what extent antimicrobial resistance generates extra costs. A new project, BURDEN (Burden of Resistance and Disease in European Nations) has recently been set up to pursue the following objectives:

To identify, on a country-by-country basis, the information needed by different stakeholders (public health experts, policy-makers, politicians, healthcare system managers) for their own assessment of the burden of infectious diseases that is caused by antimicrobial susceptible and resistant bacterial pathogens.
To generate country-specific cost models for quantifying the economic loss due to antimicrobial resistance.
To identify factors hindering efforts to control the spread of antimicrobial resistance.
To determine the excess morbidity, mortality and costs attributable to antimicrobial resistance in hospitals and intensive care units in different European countries (including the influence of a delay in appropriate therapy).
To provide direct feedback on the participating hospitals’ individual performance.
To forecast antimicrobial resistance trends by extrapolating data from the past six years from countries participating in EARSS and HELICS/IPSE.
To illustrate the financial impact of antimicrobial resistance on care in European hospitals, and to estimate the human and societal dimensions of infections caused by resistant pathogens (quality of life lost) and the repercussions for healthcare systems (loss of confidence in hospitals and medical professionals).
To achieve these objectives, data from at least one major hospital in 15 EU member states (one hospital per state), and from around 200 intensive care units located in over 20 EU member states, including Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, France, Finland, Germany, Great Britain, Hungary, Lithuania, Luxembourg, Netherlands, Norway, Poland, Portugal, Slovakia, Slovenia, Spain and Sweden will be collected and analysed over three years (January 2007 to December 2009). At the end of the second year, a first summary report on the financial impact of antimicrobial resistance on European hospital care and the wider human and societal dimensions will be presented. The final results will be presented to the European Parliament at the end of the third project year.
Information on the progress of BURDEN will be available at: http://www.eu-burden.info later in 2007. The BURDEN project is funded by the European Commission’s Directorate-General for Health and Consumer Protection (DG SANCO).


References:
Mackenzie FM, Struelens MJ, Towner KJ, Gould IM; ARPAC Steering Group; ARPAC. Consensus Conference Participants. Report of the Consensus Conference on Antibiotic Resistance; prevention and Control (ARPAC). Clin Microbiol Infect, 2005;11:938-54.
Levy SB, Marshall B. Antibacterial resistance worldwide: causes, challenges and responses. Nat Med. 2004;10(12 Suppl):S122-9
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Citation style for articles

- Article 1 : Jelinek T, Behrens R, Bisoffi Z, Bjorkmann A, Andersen P, Blaxhult A, Gascon J, Hellgren U, Petersen E, Zoller T. Recent cases of falciparum malaria imported to Europe from Goa, India, December 2006-January 2007. Euro Surveill 2007;12(1):E070111.1. Available from: http://www.eurosurveillance.org/ew/2007/070111.asp#1

- Article 2 : Payne L, Andersson Y, Blystad H, Nguyen Tran Minh N, Ruutu P, Joseph C, Ricketts K, Ledet Muller L. Outbreak of legionnaires’ disease among tourists staying at a hotel in Phuket, Thailand. Euro Surveill 2007;12(1):E070111.2. Available from: http://www.eurosurveillance.org/ew/2007/070111.asp#2

- Article 3 : Kato H, Ito Y, van den Berg R, Kuijper E, Arakawa Y. First isolation of Clostridium difficile 027 in Japan. Euro Surveill 2007;12(1):E070111.3. Available from: http://www.eurosurveillance.org/ew/2007/070111.asp#3

- Article 4 : Kafatos G, Verlander N, Gelb D, Arnold E, Charlett A. A comparison of public domain software for outbreak investigations: Epi Info and EpiData. Euro Surveill 2007;12(1):E070111.4. Available from: http://www.eurosurveillance.org/ew/2007/070111.asp#4

- Article 5 : Frank U. The BURDEN project - Assessing the burden of resistance and disease in Europe. Euro Surveill 2007;12(1):E070111.5. Available from: http://www.eurosurveillance.org/ew/2007/070111.asp#5




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